Rosen & Barkin's 5-Minute Emergency Medicine Consult (34 page)

• Aspirin 162–325 mg PO per day
  
• β-blockers:
  
  • Atenolol: Start 5 mg IV over 5 min, then 5 mg IV 10 min later, then 50–100 mg PO per day (1–2 hr after IV doses)
    
  • Esmolol: 100 μg/kg/min IV infusion (titrate by increasing 50 μg/kg/min q15min until effect—to max. dose 300 μg/kg/min)
    
  • Metoprolol: Start 5 mg IV q5min × 3, after 15 min begin 25–50 mg PO BID
    
  • Propranolol: 0.5–1 mg IV then 40–80 mg PO q6–8h
    
• Clopidogrel: 300–600 mg PO × 1, then 75 mg/d
  
• Heparins:
  
  • Enoxaparin: 1 mg/kg SC q12h, can give 30 mg IV bolus before SC dose (beware of enoxaparin in patients with renal dysfunction)
    or
    
  • Unfractionated heparin: 60 U/kg IV bolus then 12 U/kg/hr infusion (max. bolus 4,000 U, max. infusion rate 1,000 U/hr (goal is a PTT 50–75 s)
    
• Morphine sulfate: 1–5 mg IV q5–30min PRN pain
  
• Nitroglycerin: 0.3–0.6 mg SL or 0.4 mg by spray q5min followed by IV infusion beginning at 10–20 μg/min if pain persists (max. dose 200 μg/min)
  
• GP IIb/IIIa inhibitors:
  
  • Eptifibatide: 180 μg/kg IV bolus then 2 μg/kg/min infusion for 72–96 hr
    
  • Tirofiban: 0.4 μg/kg/min IV × 30 min, then 0.1 μg/kg/min infusion for 12–24h
    

• Calcium-channel blockers:
  
  • Diltiazem: Start 0.25 mg/kg IV bolus, then 0.35 mg/kg IV after 15 min if needed then 30 mg PO q6h: immediate release
    
  • Verapamil: Start 5–10 mg IV, repeat after 30 min if needed, then 80–160 mg PO q8h: immediate release
    
• ADP blocker:
  
  • Ticagrelor 180 mg PO × 1 at time PCI or no later than 1 hr post-PCI then 90 mg PO BID
    
  • Prasugrel 60 mg PO × 1 at time of PCI or no later than 1 hr post-PCI then 10 mg/d
    

• Lorazepam: 1–2 mg IV PRN anxiety
  
• Anticoagulation (instead of unfractionated heparin or enoxaparin):
  
  • Fondaparinux: 2.5 mg SC once a day or
    
  • Bivalirudin (only prior to PCI): 0.75 mg/kg IV bolus, then 1.75 mg/kg/hr IV for up to 4 hr, then 0.2 mg/kg/hr IV for up to 20 hr
    

FOLLOW-UP

• All patients with positive cardiac biomarkers, high risk for adverse outcomes by clinical prediction rules (TIMI, GRACE, PURSUIT), or significant clinical probability of acute coronary syndrome undergoing consideration for urgent or early invasive management 12–24 hr after presentation.
  
• Intensive care unit for monitoring unstable patients
  

Only those who are ruled out for acute coronary syndrome/non–Q-wave infarction can be safely sent home.

Only patients ruled out for acute coronary syndrome can be safely discharged:

• Discharged patients should follow up in 1–2 days with their primary care physician or cardiologist.
  
• Outpatient stress tests should be done within 72 hr.
  

• EKG should be done in all patients with chest pain on arrival to the ED, preferably within 10 min.
  
• Early medical therapy can reduce mortality in NSTEMI.
  
• Pitfalls:
  
  • Do not rule out infarction based on initial or single set of cardiac markers, particularly if the time from symptom onset is <4–6 hr.
    
  • Do not fail to ask about amphetamine or cocaine use.
    
  • Do not fail to ask about use of sildenafil, vardenafil, or tadalafil before giving nitroglycerin.
    

• Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction.
  J Am Coll Cardiol
  . 2007;50:e1–e157.
  
• Bonaca MP, Steg PG, Feldman LJ, et al. Antithrombotics in acute coronary syndromes.
  J Am Coll Cardiol
  . 2009;54(11):969–984.
  
• Braunwald E. Unstable angina and non–ST elevation myocardial infarction. Concise clinical review.
  Am J Resp Crit Care Med.
  2012;185:924–932.
  
• DeFilippi CR. Evaluating the chest pain patient. Scope of the problem.
  Cardiol Clin
  . 1999;17(2): 307–326.
  
• Doshi AA, Iskyan K, O’Neill JM, et al. Evaluation and management of non-ST-segment elevation acute coronary syndromes in the emergency department.
  Emerg Med Pract.
  2010;12(1):1–26.
  
• Fesmire FM, Decker WW, Diercks DB, et al. Clinical policy: Critical issues in the evaluation and management of adult patient with non-ST-segment elevation acute coronary syndromes.
  Ann Emerg Med
  . 2006;48(3):270–301.
  
• Pollack CV Jr, Braunwald E. 2007 Update to the ACC/AHA Guidelines for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: Implications for emergency department practice.
  Ann Emerg Med
  . 2008;51(5):591–606.
  
• Wackers FJ. Chest pain in the emergency department: Role of cardiac imaging.
  Heart.
  2009;95(12):1023–1030.
  
• Wright RS, Anderson JL, Adams CD, et al. ACC/AHA 2011 focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST elevation myocardial infarction.
  J Am Coll Cardiol
  . 2011;57(19):e21–e181.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Acute Coronary Syndromes
  
• Cardiac Testing
  
• Chest Pain
  

CODES

• 410.70 Subendocardial infarction, episode of care unspecified
  
• 410.71 Subendocardial infarction, initial episode of care
  
• 410.72 Subendocardial infarction, subsequent episode of care
  

BASICS

• Inadequate hydrocortisone secretion to meet body’s stress requirement
  
• Adrenal deficiency:
  
  • Inadequate cortisol
    
  • Unresponsive to stimulation with adrenocorticotropic hormone (ACTH)
    
• Functional hypoadrenalism:
  
  • Inadequate cortisol
    
  • Partial response to stimulation with ACTH
    
• Addisonian crisis (acute adrenal insufficiency):
  
  • Life-threatening emergency
    
  • Precipitated by intensification of:
    
    • Chronic adrenal insufficiency
      
    • Acute adrenal hemorrhage
      
    • Rapid steroid withdrawal
      
    • Treatment of hypothyroidism with unrecognized adrenal disease
      
    • Steroid-dependent patient under stress owing to pregnancy, surgery, trauma, infection, or dehydration
      

• Adrenal dysgenesis/impaired steroidogenesis:
  
  • Congenital hypoplasia
    
  • Allgrove syndrome:
    
    • ACTH resistance
      
    • Achalasia
      
    • Alacrima
      
  • Glycerol kinase deficiency:
    
    • Psychomotor retardation
      
    • Hypogonadism
      
    • Muscular dystrophy
      
• Congenital adrenal hyperplasia:
  
  • 21-hydroxylase deficiency accounts for 95% of cases
    
• Aldosterone synthetase deficiency
  
• Mitochondrial disease
  
• Adrenal destruction:
  
  • Autoimmune:
    
    • Autoimmune polyglandular syndrome types 1 and 2 (alopecia universalis, chronic mucocutaneous candidiasis, hypoparathyroid, thyroid autoimmunity, diabetes, celiac disease, pernicious anemia)
      
    • Adrenoleukodystrophy
      
  • Infectious:
    
    • Granulomatous: TB
      
    • Protozoal and fungal: Histoplasmosis, coccidioidomycosis, and candidiasis
      
    • Viral: Cytomegalovirus, herpes simplex virus, and HIV
      
    • Bacterial
      
    • Fungal
      
  • Metastatic tumor
    
  • Infiltration:
    
    • Sarcoid
      
    • Hemochromatosis
      
    • Amyloidosis
      
    • Iron depletion
      
• Bilateral adrenalectomy
  
• Hemorrhage:
  
  • Sepsis: Particularly meningococcemia (Waterhouse–Friderichsen syndrome), Pseudomonas infection
    
  • Birth trauma/anoxia
    
  • Pregnancy
    
  • Seizures
    
  • Anticoagulants
    
  • Rhabdomyolysis
    
• Pharmacologic inhibition:
  
  • Etomidate
    
  • Herbal medications
    
  • Ketoconazole
    
  • Metyrapone
    
  • Suramin
    

• Pituitary insufficiency
  
• Sepsis
  
• Head trauma
  
• Hemorrhage
  
• Infarction (Sheehan syndrome)
  
• Infiltration: Neoplasm, amyloid, sarcoid, and hemochromatosis
  
• ACTH deficiency
  
• Pharmacologic: Glucocorticoid administration, herbal medications